LARGO — It was sweltering in the bedroom of the Largo mobile home the day a child welfare case manager visited in July.
Yet she left 8-month-old William Hendrickson IV there with no air-conditioning and in the care of an erratic father who had been refusing to take his medication, a newly released state investigation found.
There was still time to save the child when a call was made to the Florida Abuse Hotline later that day. But the hotline operator mistakenly marked the call as a non-priority case. It wasn't until the next morning that child protective investigators arrived.
A state investigation into the death of the infant found multiple failures on the part of the child welfare system that left the boy in a room where police investigating the death recorded temperatures of 109 degrees. They include:
• The case manager who visited the home one day before the boy's death failed to take necessary action.
• The abuse hotline operator failed to code an abuse report as "immediate," which would have sent investigators to the home within four hours.
• The case manager and her supervisor failed on several occasions to escalate the case to the State Attorney's Office when it was clear their safety plan had broken down.
Hendrickson and his two-year-old sister had been under the watch of a case manager since January as a result of ongoing drug use and domestic violence between father William Hendrickson III and the children's mother, Elizabeth Rutenbeck.
In an effort to keep the family together, the couple were receiving in-homes services to improve their parenting. That safety plan included random drug testing and three "surprise" visits a week to the home, the highest level of supervision normally conducted.
During the case manager's July 25 visit, the two-year-old girl's hair was soaked with sweat and when she asked for milk, the father said he did not have any because that was normally handled by the mother. She had been jailed on a misdemeanor battery charge four days earlier after a clash with the children's grandmother.
Those were clear warning signs that the children were in danger, said Christina Spudeas, executive director of Florida's Children First, a statewide advocacy organization focused on children's rights.
"It's real simple," said Spudeas. "The baby is in danger; get him out."
The case manager should have stayed at the home until the father moved the children out of his bedroom to a cooler place in the house, Spudeas said. If he had refused, then she should have called police.
The father's parents were living in the mobile home, too. But relations between them and their son were strained and their requests that he move his children to another room or at least keep his door open were ignored.
The jailing of the mother was another missed red flag, according to the state investigation. She had been regarded as the more protective parent but now the two children were only in the care of the father, who had stopped cooperating with child welfare workers. While she was there, he refused an offer of a window air-conditioner unit for his bedroom.
This was enough grounds for the case manager or her supervisor to call the State Attorney's Office, the report states. It has a 24-hour on-call attorney who could have scheduled an emergency shelter hearing to have the children removed.
The case manager , who was not identified in the report, worked for Directions for Living, a Pinellas nonprofit contracted by the county's lead child welfare agency, Eckerd Kids. Officials from Directions declined to answer questions on the case or comment on whether the case manager or her supervisor were subject to any discipline.
Eckerd Kids spokesman Elliott Wiser said his agency is working with law enforcement and its partners — including Directions — to "make adjustments to the system of care to best serve families and children in need."
"This is a sad and unfortunate incident and we grieve with the entire Tampa Bay community," Wiser said.
A Largo police officer also visited the home the day before the boy died. He was called by the boy's grandparents and arrived at noon, about an hour after the case manager.
The report states he did not complete a police report or make a report to the child abuse hotline. He did, however, call the case manager's supervisor to make her aware of the grandparents' concerns.
That was the appropriate action for an ongoing case, said Lt. Randall Chaney of Largo Police Department's Office of Professional Standards.
The death of the child resulted in the arrest of William Hendrickson III, 26, on charges of aggravated manslaughter. He was still in jail Monday.
Rutenbeck, 24, was released Aug. 11 on a $500 bond. The 2-year-old girl is with relatives.
State law keeps the identity of callers to the state's abuse hotline confidential so its unclear who made the call the afternoon before the infant was found dead.
The Florida Department of Children and Families, which runs the abuse hotline, reviewed the call and determined that the operator "primarily focused on the details of the specific incident that was being reported."
The operator received additional training regarding the incorrect priority placed on the call. A review of the operator's other recent calls also was conducted.
DCF officials noted that the report was referred to child protective investigators within the Pinellas County Sheriff's Office by abut 6 p.m. the day before the child died. It was reviewed by three employees there and also a Eckerd Community Alternatives case manager.
"I remain committed to identifying every opportunity to improve the services provided to vulnerable children and their families in Florida," said DCF Secretary Mike Carroll. "There is also an ongoing criminal investigation and we will assist in any way possible."
Contact Christopher O'Donnell at email@example.com or (813) 226-3446. Follow @codonnell_Times.